Provider Demographics
NPI:1588083935
Name:DESAI, SHIVAM (MD)
Entity type:Individual
Prefix:DR
First Name:SHIVAM
Middle Name:
Last Name:DESAI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1755 HIGHWAY 34 E STE 2200
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-3190
Mailing Address - Country:US
Mailing Address - Phone:770-502-2175
Mailing Address - Fax:
Practice Address - Street 1:1755 HIGHWAY 34 E STE 2200
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-3190
Practice Address - Country:US
Practice Address - Phone:770-502-2175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-14
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85255207X00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty